New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter XVIII - External Appeals Of Adverse Determinations Of Health Care Plans
Part 410 - External Appeals Of Adverse Determinations Of Health Care Plans
Section 410.4 - Certification of external appeal agents

Universal Citation: 11 NY Comp Codes Rules and Regs ยง 410.4

Current through Register Vol. 46, No. 39, September 25, 2024

(a) External appeal agents shall be certified jointly by the superintendent and commissioner pursuant to section 4912 of the Insurance Law, section 4912 of the Public Health Law and the following:

(1) the applicant has demonstrated to the satisfaction of the superintendent and the commissioner that it has access to a pool of clinical peer reviewers sufficient to reasonably assure that appropriately qualified reviewers will be available on a timely basis for all appeals allowed by section 4910 of the Insurance Law and section 4910 of the Public Health Law and to avoid or minimize conflicts of interest pursuant to section 410.6 of this Part; and

(2) the applicant has demonstrated its capability to comply with all applicable laws, rules, regulations, contractual terms, policies and standards as set forth in section 4912 of the Insurance Law and section 4912 of the Public Health Law and as required by the superintendent and commissioner.

(b) Applicants for certification as external appeal agents shall submit two originals and seven copies of the application to the commissioner in the form and manner prescribed jointly by the superintendent and commissioner. Upon receipt of the application for certification, the commissioner shall transmit copies of such application to the superintendent for review.

(c) No applicant shall be certified as an external appeal agent unless the applicant's proposed fees for external appeals are determined to be reasonable by the superintendent and commissioner.

(d) In order to be certified as an external appeal agent, an applicant shall consent to cooperate in court proceedings relevant to its role as a certified external appeal agent.

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